Improving Adherence in Renal Dialysis Patients Through Electronic Interventions

Dialysis treatment non-adherence is a prevalent problem among the end-stage renal population
receiving chronic hemodialysis. The complications associated with missed or shortened
dialysis sessions are serious and frequently require emergent medical care or
hospitalization. Previous studies have shown that electronic messages have significantly
improved attendance rates in a primary care setting, but have not been validated in the
chronic dialysis population.

An electronic intervention has been developed by Epharmix, a WUSTL IDEA Labs
(ideas.wustl.edu) team, which has the capacity to use SMS text messaging to phone call
recordings to notify patients prior to each of their upcoming appointment times, with the
option of also alerting a designated patient advocate. Patients receiving the messages are
provided with key contact information for a dialysis rescheduling phone line, transportation
resources, social work services, etc. This intervention may potentially improve patient
adherence with scheduled sessions, increase patient satisfaction with their treatment and
prevent medical complications associated with missing dialysis.

This study aims to determine whether an electronic intervention, which sends SMS text
messages or phone calls of key dialysis treatment information, is able to improve dialysis
session attendance among patients with a history of poor attendance. Our secondary aim is to
identify factors that may be barriers to dialysis appointment attendance and are associated
with emergency department (ED) or hospital utilization.

Procedures: Dialysis patients of the Chromalloy American Kidney Center (CAKC) at Barnes
Jewish Hospital (BJH) and the Washington University Dialysis Center (WUDC) will be included
in this study. Two cohorts will be prospectively identified, one group consisting of
individuals with a history of occasional non-attendance to treatment sessions, defined as 2-3
missed sessions out of 24 consecutive sessions in the past 8 weeks; the other group
consisting of individuals who are frequently non-adherent (4-6 missed sessions in the past 24
consecutive sessions). Patients from each cohort will be recruited and then randomized to
either the experimental or the control group. Group A will receive the electronic
intervention featuring automated SMS text message and/or phone call prior to their
appointments; Group B will not receive any electronic intervention. After 8 weeks, crossover
will occur for both groups and the study will continue for an additional 8 weeks.

At time of enrollment, all subjects will be asked to complete a questionnaire to determine
the demographic characteristics of the study population of interest and identify possible
socio-economic factors contributing to non-adherence to the prescribed 3 times weekly
dialysis schedule. The participants' clinic records will be reviewed to determine the numbers
of missed and attended appointments, as well as records of ED visits and hospital admissions
through BJH. Subjects will be asked to complete a post-questionnaire to rate their
satisfaction with their current schedule of dialysis and their satisfaction with the
electronic intervention.

Inclusion Criteria:

- All potential subjects are between 18 and 75 years of age, and have been receiving
hemodialysis treatments, scheduled for 3 sessions/week, for at least 8 weeks at the
Chromalloy American Kidney Center or Washington University Dialysis Center.

- The individuals will be prospectively identified as whether they have a history of
occasional non-attendance to dialysis treatments, defined as 2-3 missed appointments
in the preceding 8 week period or 24 scheduled sessions. These subjects will be
enrolled as part of one cohort. Individuals who have frequent non-attendance, defined
as 4-6 missed appointments in the preceding 8 week period or 24 scheduled sessions,
will be enrolled as a second cohort.

- Subjects must be able to provide a phone number at which they can either receive SMS
text messages and/or phone calls. The cost of messages will be paid for by the sender.
Subjects must be able and willing to provide consent and authorize access of their
medical record and dialysis clinic record for study use.

Exclusion Criteria:

- Persons not receiving ongoing hemodialysis treatments or new patients with less than 8
weeks of treatments at the dialysis center.

- Persons not intended to receive 3 dialysis treatments/week for the next 8 weeks.

- Pregnant individuals.

- Persons unable to be contacted by phone call or SMS text message, or unwilling to
provide their contact number.

- Persons unwilling to consent and follow the assigned regimen and complete the required
follow up.

- Persons with severe neurological or cognitive disorders, limiting their ability to
provide consent.